An unusual ICD shock: What is the mechanism?

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Flecainide-induced incessant orthodromic atrioventricular reentrant tachycardia in Wolff- Parkinson-White syndrome: Uneven depression of accessory pathway.

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An unusual ICD shock: What is the mechanism? Rakesh Gopinathannair, MD, MA, FHRS, Brian Olshansky, MD, FHRS HeartRhythm Case Reports Volume 1, Issue 6, Pages 498-502 (November 2015) DOI: 10.1016/j.hrcr.2015.09.002 Copyright © 2015 Terms and Conditions

Figure 1 A: Upper panel shows a long RP supraventricular tachycardia (SVT) with 1:1 atrioventricular (AV) relationship (likely atrial tachycardia) with cycle length ranging from 405 to 480 msec that was detected in the VT-1 monitor zone (rate cutoff: 140 bpm). Black arrow shows PVP (postventricular atrial refractory period after premature ventricular contractions) marker indicating end of episode, as 6 of 10 beats required for continued detection is not satisfied. B: The initial SVT now transitions into a faster, short RP SVT, still with 1:1 AV relationship and cycle length from 275 to 308 msec. Red arrow shows detection of this SVT in the VT-1 zone and red asterisk indicates detection in the VF zone. Notched black arrow denotes expiration of VF duration timer. Black asterisk indicates that VF zone duration is met and device then delivers ATP at 260 msec cycle length. The red 4-pointed star following ATP denotes that this beat is ignored for reconfirmation purposes. HeartRhythm Case Reports 2015 1, 498-502DOI: (10.1016/j.hrcr.2015.09.002) Copyright © 2015 Terms and Conditions

Figure 2 A: Antitachycardia pacing results in conversion of the fast supraventricular tachycardia (SVT) to the initial SVT with a cycle length of ~420 msec. Reconfirmation following quick convert results in the device starting to charge (black arrow). Black notched arrow indicates completion of charging. B: After charging is completed, reconfirmation is performed and the device delivers a 31 joule shock (red circle). HeartRhythm Case Reports 2015 1, 498-502DOI: (10.1016/j.hrcr.2015.09.002) Copyright © 2015 Terms and Conditions

Figure 3 After the shock, supraventricular tachycardia (SVT) continues and duration is met again in the VT-1 monitor zone (V-Dur, denoted by red asterisk), but no further shock is delivered. Red arrow shows PVP (postventricular atrial refractory period after premature ventricular contractions) marker indicating end of episode, as 6 of 10 beats required for continued detection is not satisfied. HeartRhythm Case Reports 2015 1, 498-502DOI: (10.1016/j.hrcr.2015.09.002) Copyright © 2015 Terms and Conditions